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Report Bullying Form: Southern Choctaw Elementary

South Choctaw Elementary Bullying Reporting Form

Today's Date

01. Name of Victim:

Age of Victim:

Age of Offender (If Known):

Name of Additional Alleged Offender (If Any):

Age of Offender (If Known)

03. On what date did the incident happen?

Additional date the incident happen:

Electronic Communications or Other (Describe):

09. If yes, how many days was the student victim absent from school as a result of the incident?

11. What did the alleged offender(s) say or do?12. Why did the bullying, harassment or intimidation occur?13. Is there any additional information you would like to provide?10. Did a psychological injury result from this incident?06. Did a physical injury result from this incident?07. If there was a physical injury, do doctors think there will be permanent effects?08. Was the student victim absent from school as a result of this incident?04. Where did the incident happen (Choose all that apply)?

On school property

On school property

At a school-sponsored activity or event off school property

05. Place check next to the statement(s) that best describes what happened (Choose all that apply):

Hitting, kicking, shoving, spitting, hair pulling, or throwing something

Coercing another person to hit or harm the student

Repeated teasing, name-calling, making critical remarks, or threatening, in person or by other means

Making rude and/or threatening gestures

Intimidating, bullying, extorting, or exploiting

Spreading harmful rumors or gossip

Electronic Communications (specify below)

Other (specify below)

Is he/she a student?School:Is he/she a student?School (If Known):School:

Choctaw County Schools
107 Tom Orr Drive, Butler, AL 36904

P: 205-459-3031 - F: 205-459-3037

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